Hydroxyethyl Starch for Fluid Replacement Therapy in High-Risk Surgical Patients: Context and Caution

Fernando G Zampieri, Alexandre B Cavalcanti

JAMA 2020 Jan 21;323(3):217-218

Hydroxyethyl starch (HES) solutions have had a turbulent history as resuscitation fluids. There was initial optimism that these products would efficiently expand the intravascular space with a prolonged intravascular half-life and therefore would be “volume sparing,” with less edema.

However, enthusiasm was tempered when HES solutions were reported to be harmful when administered to critically ill patients, including those with sepsis. Despite these concerns, HES is still used in surgery under the premise that lower doses infused under strict protocols would be safe. Futier and colleagues report the results of the FLASH multicenter randomized clinical trial, which assessed the effects of HES vs saline for fluid resuscitation in patients undergoing major abdominal surgery. The primary end point was a composite of death and occurrence of renal, respiratory, cardiovascular, infectious, or surgical complications. Several secondary and exploratory end points were also reported. The FLASH clinical trial suggests that a protocolized surgical optimization approach using HES vs saline resulted in minor physiological benefits on day 1 that vanished soon thereafter. However, important morbidity for patients, specifically acute kidney injury, may be related to HES use.